Survival Rises When Hospitals Heed All Heart Attack Guidelines

But one out of four hospitals aren't adhering completely, study finds

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TUESDAY, April 25, 2006 (HealthDay News) -- When hospitals follow all of the nine medication guidelines set forth by two leading heart groups, more heart attack patients survive.

That's the conclusion of a study appearing in the April 26 issue of the Journal of the American Medical Association that found mortality rates were around 4.15 percent at hospitals that followed the guidelines compared to over 6.3 percent for medical centers that didn't heed all the recommendations.

Unfortunately, the study also found that as many as one out of four hospitals isn't following all of the guidelines.

"There is a high correlation between the centers that followed the guidelines well and a lower mortality," said study author Dr. Eric Peterson, an associate professor in the department of medicine in the division of cardiology and vice chairman of quality at Duke University Medical Center.

However, "we found that up to a quarter of the time, physicians were failing to deliver evidence-based medicine when patients are eligible to receive it. There are centers were it's more like a coin flip, and that degree of variation is frightening because if you come in with acute coronary syndrome, you usually don't have much of a choice as to where you go," he said.

About 865,000 heart attacks occur each year, according to the American Heart Association (AHA). About 171,000 people die from heart attacks annually.

The current study looked at the compliance of 350 medical centers to medication guidelines from both the AHA and the American College of Cardiology (ACC). These nine medication guidelines covered both in-hospital medications and those prescribed upon discharge. Some medications, such as aspirin and beta blockers, are recommended for people with suspected heart attacks in the hospital, while others, such as statins to lower cholesterol, are recommended when a patient is being discharged.

Sometimes, it's not in a patient's best interest to strictly follow the guidelines. For example, beta blockers aren't recommended for people with asthma because they can cause shortness of breath. In cases such as this, said Peterson, doctors were allowed to mark patients as ineligible for the study.

The researchers found that all of the guidelines were followed for 74 percent of the eligible cases. Mortality rates were 6.31 percent in hospitals with the lowest compliance and 4.15 percent in hospitals with the highest adherence. Every 10 percent increase in guideline compliance was matched with a 10 percent decline in the risk of mortality, according to the study.

"I do believe this is strong evidence that we don't need to worry about following 'cookbook' medicine. Delivering consistent evidence-based medicine makes a difference. Hospitals that delivered consistently had better outcomes," said Peterson.

Peterson also pointed out that these findings may underestimate the number of hospitals that aren't following all of the ACC/AHA guidelines, because the centers included in this study were hospitals that volunteered to participate and be evaluated.

Dr. Stephen Siegel, a cardiologist at New York University Medical Center, said this study showed "compliance with accepted guidelines does improve quality of care in terms of patient outcomes."

But, he said, it may not mean that one in four hospitals wasn't following the standards of care; it simply might have been a case of bad documentation.

"Sometimes, there's a reason you don't give aspirin or a beta blocker, and you don't necessarily write it in the chart, so a lot of this seems like a question of improved documentation," he said.

Siegel also expressed concern that some hospitals may become too focused on outcome data, because patients may start looking at this and making decisions about where they receive their care. The problem with this is that some hospitals may turn away high-risk patients or stop doing high-risk surgeries because they'll bring down the hospital's overall performance.

"We've seen cases where people were turned away from other hospitals because they're too high-risk. When outcomes data starts permeating the entire health-care environment, it can be disastrous."

But, Peterson pointed out that these interventions were simple ones -- prescribing a medication -- and that strictly following the guidelines in these cases led to fewer deaths.

SOURCES: Eric Peterson, M.D., associate professor, department of medicine, division of cardiology, and vice chairman, Quality, Duke University Medical School, Durham, N.C.; Stephen Siegel, M.D., cardiologist and clinical assistant professor, New York University Medical Center and School of Medicine, New York City; April 26, 2006, Journal of the American Medical Association